Guest Form

Holidays

Which holiday do you wish to apply for?

Your Details

Name: Home Tel No:

Email: Mobile:

Postal Address: Postcode:

Where do you live? How many family members regularly care for you?:

Next of Kin Details

Name: Relationship:

Mobile: Email:

Postal Address: Postcode:

Home Telephone Number:

GP Details

GP Name: GP Telephone Number:

Postal Address: Postcode:

We may need to contact your Doctor - please indicate your agreement

Guest Information

Date of Birth: Height:

Age: Weight:

Do you require a specific diet?

If yes please give details

My disabling condition is:

Are you able to bear your own weight?

Do you use a wheelchair with a fitted belt?

Is your wheelchair?

Would you be bringing your wheelchair on holiday?

Would you need to stay in your wheelchair on a coach?

Would you require assistance with transfers out of your wheelchair?

Do you use a hoist or other mobility aids? if YES please list below.

Medical Conditions

Please indicate if you have any of the following:

Diabetes

Mobility problems

Asthma

Incontinence – Urine/Double

Heart problems

Respiratory Problems

Nervous/Mental Health Problems

Learning Difficulties

Epilepsy If so, when was the date of your last seizure: How often are your seizures?

Allergies If yes, please provide details:

Anything else that may be relevant?, if so please list

I need assistance in the following areas

The services of a nurse

Medication

Eating

Washing

Dressing

Using the toilet

Transfers

Attention during the night

If YES please give details in full, especially services of nurse, as much information as possible helps us greatly.

Care Plan

FOR YOU TO BE ACCEPTED ON THIS HOLIDAY WE WILL REQUIRE AN UP-TO-DATE CARE PLAN.

Please either attach one with this application, send a hardcopy to the 3H office or contact 3H and we can send you a template form.

Please list all medication and dosage

Additional Information

How did you find out about 3H Fund Holidays?

Why do you want to go on a 3H Fund Holiday?

How will you be travelling?

I would prefer future correspondence from 3H by:

Data Protection

Under the data protection regulations 1998 and to comply with new regulations coming into effect from 25 May 2018, we need your consent in respect of the following, and would be grateful if you would tick your agreement in the boxes provided:

1. All your personal data shall be kept confidentially by 3H for a time deemed necessary. 2. 3H will forward your personal data to the necessary parties who will have been made aware of their obligations to abide to all aspects of the new data regulations and particularly in respect of confidentiality and safe keeping. 3. 3H Fund may wish to publish photographs with your first name and/or short video clips which include you, in their various publications, 3H website, Facebook, Twitter and may use your details for other promotional and reporting purposes.

Under the new regulations you have the right to request personal data held about you by us and following your request this information will be returned to you within a month.